Observations and Considerations for Implementing Remote Acoustic Voice Recording and Analysis in Clinical Practice

OBJECTIVES/HYPOTHESIS

Remote voice recording and acoustic analysis allow for comprehensive voice assessment and outcome tracking without the requirements of travel to the clinic, in-person visit, or expensive equipment. This paper delineates the process and considerations for implementing remote voice recording and acoustic analysis in a high-volume university voice clinic.

STUDY DESIGN

Clinical Focus.

METHODS

Acoustic voice recordings were attempted on 108 unique patients over a 6-month period using a remote voice recording phone application. Development of the clinical process including determining normative data in which to compare acoustic results, clinician training, and clinical application is described. The treating Speech Language Pathologists (SLPs) were surveyed 2 months after implementation to assess ease of application, identify challenges and assess implementation of potential solutions.

RESULTS

Of 108 unique patients, 83 patients were successful in completing the process of synchronous remote acoustic voice recording in conjunction with their SLP clinician. The process of downloading the application, setting up, and obtaining voice recordings was most commonly 10-20 minutes according to the 8 SLPs surveyed. Challenges and helpful techniques were identified.

CONCLUSIONS

Remote acoustic voice recordings have allowed SLPs to continue to complete a comprehensive voice evaluation in a telepractice model. Given emerging knowledge about the viability of remote voice recordings, the success in obtaining acoustic data remotely, and the accessibility of a low-cost app for SLPs makes remote voice recordings a viable option to facilitate remote clinical care and research investigation.

Predictors of Voice Therapy Attendance in an Interdisciplinary Care Model

OBJECTIVES/HYPOTHESIS

The purpose of this study is to elucidate factors associated with voice therapy attendance within the interdisciplinary care model.

STUDY DESIGN

This was a retrospective review.

METHODS

Patients referred for voice therapy following interdisciplinary evaluation involving speech language pathology and laryngology were included. Independent variables were (1) duration between interdisciplinary voice evaluation and first voice therapy session, (2) plan of care determined at the time of evaluation, (3) mode of voice therapy delivery, and (4) stimulability for improvement during evaluation. Voice therapy attendance was measured as (1) attendance to the first voice therapy session and (2) overall voice therapy attendance.

RESULTS

Of 272 patients referred for voice therapy, 69.12% attended the first session, 17.28% canceled/no-showed (C/NS), and 13.6% did not schedule the first session. Of 235 patients who scheduled voice therapy, 48.94% attended all their scheduled sessions, and 51.06% C/NS at least one session. Patients with a plan of care including voice therapy + surgery were 86% less likely (risk ratio [RR] = 0.14, P = 0.0014) to C/NS any of their voice therapy sessions. In contrast, patients with plan of care including voice therapy + medication were more likely to C/NS at least one voice therapy session (RR = 1.27, P = 0.1419), although this finding was not significant. No other covariates had a significant impact on voice therapy initiation or overall attendance.

CONCLUSIONS

This study provides further support for the positive impact of interdisciplinary evaluation on voice therapy initiation. However, once voice therapy is initiated, overall C/NS rates are persistently high, consistent with previous investigations of voice therapy dropout. Our findings suggest that plan of care determined at the time of evaluation may have an impact on voice therapy attendance.

A Machine-Learning Algorithm for the Automated Perceptual Evaluation of Dysphonia Severity

OBJECTIVES

Auditory-perceptual assessments are the gold standard for assessing voice quality. This project aims to develop a machine-learning model for measuring perceptual dysphonia severity of audio samples consistent with assessments by expert raters.

METHODS

The Perceptual Voice Qualities Database samples were used, including sustained vowel and Consensus Auditory-Perceptual Evaluation of Voice sentences, which were previously expertly rated on a 0-100 scale. The OpenSMILE (audEERING GmbH, Gilching, Germany) toolkit was used to extract acoustic (Mel-Frequency Cepstral Coefficient-based, n = 1428) and prosodic (n = 152) features, pitch onsets, and recording duration. We utilized a support vector machine and these features (n = 1582) for automated assessment of dysphonia severity. Recordings were separated into vowels (V) and sentences (S) and features were extracted separately from each. Final voice quality predictions were made by combining the features extracted from the individual components with the whole audio (WA) sample (three file sets: S, V, WA).

RESULTS

This algorithm has a high correlation (r = 0.847) with estimates of expert raters. The root mean square error was 13.36. Increasing signal complexity resulted in better estimation of dysphonia, whereby combining the features outperformed WA, S, and V sets individually.

CONCLUSION

A novel machine-learning algorithm was able to perform perceptual estimates of dysphonia severity using standardized audio samples on a 100-point scale. This was highly correlated to expert raters. This suggests that ML algorithms could offer an objective method for evaluating voice samples for dysphonia severity.

LEVEL OF EVIDENCE: 4

Injection laryngoplasty as an effective treatment method for glottal insufficiency in aged patients

PURPOSE

The purpose of the study was to assess outcomes of injection laryngoplasty (IL) for treating glottal insufficiency in elderly patients with presbyphonia or unilateral vocal fold paralysis (UVFP).

METHODS

A single-center retrospective study was performed. The study group consisted of 34 patients with glottal insufficiency aged between 60 and 82 years who had been treated with injection laryngoplasty. Of them, 16 patients were diagnosed with presbyphonia and 18 with UVFP.

RESULTS

After IL, glottal closure improved in both groups. The change was statistically significant in the patients with presbyphonia (marginal homogeneity test MH = 3.80; p < 0.001) and in the UVFP patients (MH = 4.04; p < 0.001). Voice quality improved after IL and 12 months after surgical intervention remained significantly better compared to before augmentation (MH tests were statistically significant at p < 0.05 for R, B, A, and S parameters). In the patients with UVFP, significant improvement was observed in 7 of 12 evaluated parameters (Jitt, RAP, PPQ, Shim, APQ, sAPQ, and NHR) but in the patients with presbyphonia only average fundamental frequency (F0) improved significantly. Comparison of the Voice Handicap Index outcomes before and 12 months after surgery showed improvement of subjectively assessed voice quality in both groups; however, the change was statistically significant only in the UVFP patients.

CONCLUSIONS

Injection laryngoplasty is a safe and effective treatment method for glottal insufficiency in the elderly. This study shows a significant and clinically relevant improvement to at least12 months, especially in patients with UVFP.

Vocal outcomes after COVID-19 infection: acoustic voice analyses, durational measurements, self-reported findings, and auditory-perceptual evaluations

PURPOSE

The ongoing literature suggests that COVID-19 may have a potential impact on voice characteristics during the infection period. In the current study, we explored how the disease deteriorates different vocal parameters in patients who recovered from COVID-19.

METHODS

A total of 80 participants, 40 patients with a prior history of COVID-19 (20 male, 20 female) with a mean age of 39.9 ± 8.8 (range, 21-53) and 40 gender and age-matched healthy individuals (mean age, 37.3 ± 8.8; range, 21-54) were included to this study. The data of acoustic voice analyses, durational measurements, patient-reported outcomes, and auditory-perceptual evaluations were compared between the study group and the control group. Correlation analyses were conducted to examine the association between the clinical characteristics of the recovering patients and measured outcomes.

RESULTS

Maximum phonation time (MPT) and the scores of both Voice Handicap Index-10 (VHI-10) and Voice-Related Quality of Life (V-RQOL) questionnaires significantly differed between the groups, which was more evident in female participants. The overall severity score of dysphonia was found to be higher in the study group than the control group (p = 0.023), but gender-based comparisons reached significance only in males (p = 0.032). VHI-10 and V-RQOL revealed significant correlations with the symptom scores of the disease.

CONCLUSIONS

Patients with a prior history of COVID-19 had significantly lower MPT, increased VHI-10 scores, decreased voice-related quality of life based on the V-RQOL questionnaire, and higher overall severity scores in the auditory-perceptual evaluation. Self-reported voice complaints disclosed close relationships with the symptom scores of COVID-19 disease.

Cultural Competency in Voice Evaluation: Considerations of Normative Standards for Sociolinguistically Diverse Voices

AIM

Significant differences exist in anatomical, acoustic, and aerodynamic parameters for nonspeech tasks between culturally and linguistically diverse sample populations. There is a need for expansion of the normative acoustic data to include sociolinguistically diverse groups to ensure that clinical objective measurements are accurately classifying the voice quality of all individuals. This study examined objective measures of voice quality assessment of monolingual speakers of Standard American English (SAE) with sequential bilingual, native (L1) French and Spanish speakers on perturbation, noise, spectral/cepstral analyses, and compared ratings on auditory-perceptual assessment with acoustic data secondary to degree of accentedness.

METHOD

Thirty speakers with normal voice quality were rated on the Consensus Auditory-Perceptual Evaluation of Voice scale. Voice quality measures were analyzed using the Multi-Dimensional Voice Program and Analysis of Dysphonia in Speech and Voice. A measure of accentedness of SAE was calculated using an informal task by two evaluators.

RESULTS

Objective acoustic measures of jitter and all-voiced cepstral peak prominence were statistically significant between SAE speakers and L1 Spanish and French speakers. SAE speakers demonstrated significantly higher group mean cepstral peak prominence for the all-voiced sentence ("We were away a year ago.") than native French and Spanish speakers. There were no significant differences in perception of voice quality and acoustic measures secondary to degree of accentedness of the non-native SAE speakers.

CONCLUSION

It is important to engage and strengthen voice diagnostic measures to support culturally competent service delivery for the diversifying clinical population. Normative databases established on SAE speakers should reflect the statistically significant differences evidenced between diverse sociolinguistic populations in anatomical, auditory-perceptual, aerodynamic, and acoustical parameters.

Respiratory Function and Voice: The Role for Airflow Measures

OBJECTIVE

To clarify the relationship between voice and respiratory function, and to understand the role for airflow measures in the evaluation of voice patients.

METHODS

Literature searches of MEDLINE (Ovid) and Web of Science were performed on April 6, 2020, to include articles written in English that both discussed voice in relation to lower respiratory function and reported evaluation of airflow. Search strategies included the keywords voice, respiratory, airflow, and aerodynamic measures. Data were extracted from articles that met inclusion criteria.

RESULTS

Twenty studies were included for review. Fourteen (70%) studies evaluated at least 1 spirometric respiratory measure, including Forced Vital Capacity, Forced Expiratory Volume in 1 second, and Forced Expiratory Flow. Other measures assessed included mean flow rate, mean peak airflow, phonatory airflow, inspiratory airflow, expiratory airflow, and phonation quotient. Notably, four studies which included pulmonary function tests (PFTs) as part of voice evaluation discovered previously undiagnosed respiratory disease in their study populations.

CONCLUSION

This review confirms that respiratory function contributes significantly to voice and reveals that few studies have explored the role for airflow measures in clarifying this relationship. Including airflow measures such as PFTs in standard voice evaluation may allow recognition of underlying respiratory disease contributing to voice dysfunction. Further research is recommended to establish indications and diagnostic criteria for the use of PFTs in voice patients.

Validation of the Brazilian Portuguese CAPE-V Instrument-Br CAPE-V for Auditory-Perceptual Analysis

INTRODUCTION

The Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) scale is a modern, clinical-scientific approach to voice analysis. It has been translated and culturally adapted to Brazilian Portuguese, but it still lacks validation.

OBJECTIVE

To validate the Brazilian Portuguese version of the CAPE-V scale using the previously translated and culturally adapted version.

METHOD

Forty voice samples were selected (30 dysphonic, 10 nondysphonic), and the degree of vocal deviation was evaluated by a committee of three voice specialists. Nine voice specialists judged the 40 voice samples plus 20% repetition (total of 48 samples) using the CAPE-V. To ensure construct validity of the CAPE-V, its analysis was compared to the Grade-Roughness-Breathiness-Asthenia-Strain (GRBAS) scale that was performed 48-72 hours later. Finally, the intra- and inter-rater reliability values were verified and the correlation between the nine judges and the previously defined evaluation was analyzed.

RESULTS

The Brazilian CAPE-V presented significant intra (0.860-0.997) and inter-rater reliability values (0.707-0.964) for the overall degree and strong correlation with GRBAS (above 0.828). Deviant voice quality had greater consensus among raters than normal voices. A strong correlation was observed between the analysis of the nine raters and that of the committee.

CONCLUSION

CAPE-V is an important diagnostic instrument that contributes to the standardization of vocal quality evaluation in several languages, including Brazilian Portuguese. Thus, its usefulness is neither related to a single language nor to a single set of raters.

Speech Pathology Utilization and Stroboscopy Before and After Adult Medialization Laryngoplasty

OBJECTIVES

Evaluation of trends and utilization of speech-language-pathology (SLP) services, including stroboscopy, before and after medialization laryngoplasty (ML) over 11 years.

METHODS

Retrospective national US database study conducted using OptumLabs Data Warehouse. Study cohort included patients (age ≥18 years) who underwent ML between January 2007 and December 2016. Primary outcomes were rates of SLP visits in the 12 months before and 12 months after ML. Linear regression analysis was performed assessing for trends utilization across years. Secondary outcomes were predictors of utilization After-ML using multivariable logistic regression.

RESULTS

1114 patients met criteria. Services, including stroboscopy, were utilized by 774 (69%) Before-ML and 697 (63%) After-ML. SLP services, excluding stroboscopy, were utilized by 512 (46%) Before-ML and 478 (43%) After-ML. Vocal cord paralysis was the most common diagnosis, 945 (84.8%) patients. Other service billed were stroboscopy, [Before-ML 676 (60.7%); After-ML 567 (50.9%)], voice evaluation [Before-ML 431(38.7%); After-ML 366 (32.9%)], voice therapy [Before-ML 309 (27.7%); After-ML 339 (30.4%)], laryngeal function studies, [Before-ML 175 (15.7%); After-ML 164 (14.7%)], swallow evaluations [Before-ML 150 (13.5%); After-ML 90 (8.1%)], and swallow therapy [Before-ML 53 (4.8%); After-ML 47 (4.2%)]. SLP utilization Before-ML predicted SLP utilization After-ML [Odds Ratio (95% Confidence Interval): 9.31 (6.78, 12.77)]. Nearly half (49%) of visits occurred in the 6 months around ML. Of those who had voice therapy, the majority (73.7%) had a total of 1 to 5 sessions.

CONCLUSION

Based on this retrospective US national database study, SLP services and stroboscopy are a complementary component of assessment and treatment of patients who undergo ML with the majority of services occurring in the 3 months before and after ML. Future work would benefit from outcome data.

Revisiting Sustained Phonation Time of /s/, /z/, and /a/

PURPOSE

Research studies of maximum phonation time, have questioned its validity and value as a tool to assess laryngeal competence. This study proposes a fresh look at phonation time, from a different perspective. The interrelationships of the durations between semiocclusion vs. open vocal tract (/s/-/z/ vs. /a/) and voiced vs voiceless (/z/-/a/ vs. /s/) sound are examined to determine whether this approach might provide additional clinical insight into the respiratory phonatory efficiency of patients.

METHODS

Comfortable sustained phonation time of /s/, /z/ and /a/ was collected as part of the voice evaluation of patients referred by laryngologists for voice therapy. Inclusionary criteria: male and female subjects 19 years of age or older. Exclusionary criteria: autoimmune disorders, malignancies, major pulmonary/respiratory disorders.

RESULTS

A total of 218 patients (150 females and 68 males) mean age of 53.6 met all the criteria. Means, standard deviations and t test were conducted to determine whether significant differences existed. t test results indicate significance between s/z P = 0.002 and z/a P = 0.004 for females but only slight significance in s/a P = 0.03 for males. Close analysis of individual results observed four (4) different conditions or effects of fricative/semiocclusion and voicing: the close durations of the /s/ and /z/ relative to the /a/; the /z/ and /a/ are close in duration relative to the /s/; the spread of more than 5 seconds between /s/, /z/ and /a/ relative to the others; and similar duration of /s/, /z/, and /a/.

CONCLUSION

Significant differences exist in the durations of comfortable phonation time of sustained /s/ and /z/ and /a/ thought to be related to effects of semiocclusion, fricative consonants, and voicing. Phonation time should be seen not only in terms of duration, but the interplay of the phonemic qualities of the sounds as they relate of laryngeal efficiency.

The Usefulness of Auditory Perceptual Assessment and Acoustic Analysis for Classifying the Voice Severity

OBJECTIVE

The aims of this study were to (1) to determine the cut-off values of parameters related to auditory perceptual assessment (visual analog scale) and acoustic analysis (cepstral peak prominence, low frequency/high frequency ratio, cepstral peak prominence standard deviation, low frequency/high frequency ratio standard deviation, acoustic voice quality index, and cepstral spectral index of dysphonia) for predicting the voice severity within a Korean population; and (2) to verify the discriminative power of these cut-off values.

METHODS

Voice samples of 1,029 subjects who visited Pusan National University Hospital, South Korea to be treated for swallowing or voice evaluation from January 2018 to December 2018 were analyzed in this retrospective study. The acoustic analysis of cepstral parameters, cepstral spectral index of dysphonia, and acoustic voice quality index were calculated using the Computerized Speech Lab and Praat software. The cut-off values of parameters predicting the voice severities were obtained using receiver operating characteristic analysis. Through this analysis, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were measured.

RESULTS

High reliabilities of auditory perceptual assessments were observed for the auditory perceptual assessment. The cut-off values of parameters predicting voice severities had high sensitivity, specificity, and area under the curve.

CONCLUSIONS

The cut-off values of parameters predicting the voice severities demonstrated a high power to discriminate for classifying the voice severities within a Korean population. The results of this study could be used as objective criteria to screen for severities of voice disorders.

Components of Voice Evaluation

This article provides a concise review of contemporary options for evaluating voice disorders. Focus is given to patient history and patient-derived voice handicap and quality of life assessments, clinician-derived perceptual analysis of voice, and finally flexible and rigid, high-definition laryngoscopy with videostroboscopy to fully evaluate laryngeal function and biomechanics.

The Utility of Pulmonary Function Testing in Patients Presenting With Dysphonia

OBJECTIVE

We aimed to evaluate the utility of pulmonary function testing (PFT), particularly forced expiratory flow (FEF) 25-75%, in patients presenting with dysphonia.

STUDY DESIGN

A retrospective chart review was carried out.

METHODS

Records of 199 patients who presented with dysphonia were reviewed to determine whether in-office PFTs, which we perform routinely, lead to new pulmonary diagnoses or the need for additional pulmonary medications, after assessment by a pulmonologist. Of particular interest was evaluating if FEF25-75% of predicted values less than 80% can be used as a marker for occult pulmonary disease in patients presenting with dysphonia.

RESULTS

Of the 199 patient charts reviewed, 129 were female and 70 were male. The age of patients ranged from 18 to 88 years, with a mean of 46.8 years. The body mass index ranged from 17.5 to 53.4 kg/m². One hundred five (52.8%) patients had FEF25-75% values less than 80% of predicted (poor midflow values). Of these patients, 76 (72.4%) were referred to a pulmonologist, 22 of 76 (28.9%) completed the referral, and 17 of 22 (77.3%) received a new pulmonary diagnosis or change in medications. Of the 155 patients without a history of pulmonary disease, 76 had poor midflow values, 57 (75%) of these patients were referred, and 12 of 57 (21%) completed the referral. Eight (67%) of these 12 patients were diagnosed with a previously unrecognized pulmonary disorder. Of the 44 patients with a prior history of pulmonary disease, 29 (65.9%) had poor midflow values. Nineteen (65.5%) of these patients were referred, and 9 (47%) received a new pulmonary diagnosis or a change in their medications. There were 51 classically trained singers and 148 nonclassically trained singers or nonsingers. There was no significant difference in average midflow values between the two groups (80.96 ± 24.7 and 80.73 ± 28.4, respectively) or in the percentage of classically trained singers with poor midflow values compared with nonsingers (53.5% vs. 49%, respectively).

CONCLUSION

This study suggests that patients with dysphonia may have unrecognized underlying pulmonary disease, and PFT should be considered as part of the routine initial voice evaluation for patients presenting with dysphonia.

Comparison of Two Perceptual Methods for the Evaluation of Vowel Perturbation Produced by Jitter

OBJECTIVES

To explore perceptual evaluation of jitter produced by fundamental frequency (F0) variation in a sustained vowel /a/, using two different methods. One is based on listener's internal references and the other is based on external references provided by the experimenter.

METHODS

We used two methods: one is magnitude estimation-converging limits (ME-CL), which is close to the standard approach used by speech therapists when they use numerical estimations and their own standards, and other is intramodal matching procedure (IMP), where each matched stimulus is to be compared with a fixed-set matching stimuli. Systematic variations were introduced in vowel /a/ by Linear Prediction Coding synthesis using an F0 contour function obtained from a statistical jitter model. Six jitter values were used for each of two reference F0 values. Three groups of listeners were tested: expert speech therapists, speech therapy students, and naïve listeners.

RESULTS

Perceptual functions appear to be similar and linear for both methods as the theory predicts. The answers of all groups of listeners tested with ME-CL present higher standard deviations than for IMP. When subjects were tested with IMP, intrareliability and interreliability measurements show a significant improvement for both expert and naïve listeners.

CONCLUSIONS

Both intraindividual and interindividual differences for expert speech therapists could be better managed when tested with an IMP than when they use numerical estimations and internal standards to evaluate vowel perturbation produced by jitter. This procedure could be the basis for the development of a clinical evaluation tool.